Employers in the United States have become more cognizant

n report n Impact of Overactive Bladder on Work Productivity in the United States: Results From EpiLUTS Chris C. Sexton, PhD; Karin S. Coyne, PhD, MPH; Vasudha Vats, MPH; Zoe S. Kopp, PhD, MPH; Debra E. Irwin, MSPH, PhD; and Todd H. Wagner, PhD Abstract Objective: Little research has focused on the impact of overactive bladder (OAB) on work productivity. Consequently, the impact of OAB and other lower urinary tract symptoms (LUTS) on work productivity was evaluated in employed men and women aged 40 to 65 in the United States. Study Design: Data from a population-based, cross-sectional Internet survey were used to examine the impact of OAB symptoms on work productivity. US participants aged 40 to 65 working full- or part-time were included in the analysis. Participants were asked about the incidence of OAB and other LUTS and a series of questions about work productivity. Methods: Descriptive statistics and linear and logistic regressions were used to evaluate outcome differences for men and women by the OAB groups of no/minimal symptoms, continent OAB, and incontinent OAB. Results: The response rate was 60%, and a total of 2876 men and 2820 women were analyzed. Men and women with incontinent OAB reported the lowest levels of work productivity and highest rates of daily work interference. Storage symptoms associated with OAB were most consistently associated with work productivity outcomes; however, significant associations were also found for other storage, voiding, and postmicturition LUTS. Conclusion: In this large US population based study, OAB was highly prevalent and was associated with lower levels of work productivity. These findings add to the literature documenting the burden of OAB and other LUTS, underscoring the need for increased screening and treatment. (Am J Manag Care. 2009;15:S98-S107) For author information and disclosures, see end of text. Employers in the United States have become more cognizant in recent years of the effects of employee health on work productivity and healthcare costs, leading many employers to offer wellness programs in addition to employee health benefits. 1 Various health conditions have been associated with employee nonattendance (absenteeism) and lack of productivity (presenteeism), including hypertension, angina, depression, irritable bowel syndrome, allergies, bipolar disorder, diabetes, and obesity. 2-8 Goetzel et al 1 analyzed 5 data sources and found absenteeism to be most related to depression/mental illness, cancer (any), respiratory disorders, and asthma; presenteeism was most related to migraine/headache, respiratory disorders, and depression/ mental illness. 1 Despite this growing recognition of the importance of health in the workplace, little research has assessed the impact of overactive bladder (OAB) on work productivity. OAB is a symptomatic condition characterized by urinary urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia. 9-11 The prevalence of OAB is fairly high and ranges from 12% to 22% in Europe and 16% to 17% in the United States. 12-14 OAB has far-reaching effects on patients daily lives that can present barriers to work functioning, such as needing to take frequent breaks to use the bathroom. 9,10 While the symptom burden and impact of OAB on health-related quality of life have been well documented, 9,10,14-16 few studies have evaluated the effect of OAB on work productivity. Irwin et al 15 examined employment issues related to OAB and found that OAB led Managed to worry about meeting Care interruption, & factored into work location and scheduling decisions, and influenced deci- Healthcare Communications, LLC sions relating to voluntary termination or early retirement, particularly among men with incontinent OAB. Data from EPIC indicated that men and women with OAB were more likely to report absenteeism and presenteeism compared with controls. 17 However, differences in the culture of work across countries may influence how OAB impacts men and women in the workplace, highlighting the need for more research in countries not sampled in prior population-based studies. There is also a need to assess aspects of daily work functioning that may be particularly impacted by OAB symptoms. Hu et al 18 analyzed survey data from the NOBLE (National Overactive Bladder Evaluation) study and found significant decreases in work S98 n www.ajmc.com n March 2009

Impact of Overactive Bladder on Work Productivity in the United States: Results From EpiLUTS productivity associated with OAB compared with age- and sex-matched controls. They estimated lost productivity costs of $841 million, 98% of which was attributable to persons under age 65. To further examine the above issues, data from the EpiLUTS (Epidemiology of Lower Urinary Tract Symptoms) study were used to assess the impact of OAB on work productivity among employed men and women under the age of 65 in the United States. METHODS Study Design A population-based, cross-sectional Internet survey was conducted in the United States, the United Kingdom, and Sweden to examine the prevalence and symptom-specific bother of OAB and other lower urinary tract symptoms (LUTS) as well as to evaluate the impact of these symptoms on quality of life, work productivity, mental health, and sexual health. Given the unique considerations surrounding the work environment in each country, the present study focused only on US data. A total of 20,000 men and women from the United States aged 40 years and older were targeted for recruitment from an Internet-based panel between June 5, 2007, and July 8, 2007. The rationale for this recruitment approach, study design, and further description of the Internet survey are described elsewhere. 19,20 The present analysis includes US participants aged 40 to 65 years who reported working full- or part-time. Survey Questionnaire The following LUTS were assessed: urinary frequency, urinary urgency, nocturia, incontinence (stress, urgency, mixed, nocturnal enuresis, postmicturition, leaking during sexual activity, and leaking for no reason), weak stream, terminal dribble, hesitancy, straining, intermittency, split stream, incomplete emptying, bladder pain, and dysuria. The response options for the majority of LUTS were on a 5-point Likert scale ( never, rarely, sometimes, often, and almost always ). For every LUTS occurrence response of rarely or more often, participants were asked how bothered they were by the particular LUTS. Similarly, bother ratings were assessed on a 5-point Likert scale ( not at all, a little bit, somewhat, quite a bit, and a great deal ). OAB was determined by the presence of urinary urgency or urgency urinary incontinence (UUI). The presence of urinary urgency was a response of sometimes or more often to the following question: During the past 4 weeks, how often have you had a sudden need to rush to urinate? By sudden need to rush to urinate we mean a sudden intense feeling of urgency where you feel you must urinate immediately. Presence of UUI was a yes response to the following question: During the past 4 weeks, did you leak urine in connection with a sudden need to rush to urinate? Based on their responses to the questions about OAB and other LUTS, participants were divided into the following OAB subgroups: no/minimal symptoms (absence of any LUTS response of sometimes or more often); continent OAB (presence of urinary urgency with absence of UUI); and incontinent OAB (presence of UUI; with or without urinary urgency). Participants with other non-oab LUTS (eg, weak stream, terminal dribble, straining) at least sometimes or more often were not included in this subgroup analysis. Analyses were also conducted using a cutpoint for urinary urgency of often or more often. All participants who responded that they worked either full- or part-time were asked questions about work productivity. If they had more than one job, respondents were instructed to complete the questionnaire based on their main job only. Five symptom-related work-impairment questions were adapted from the Output Demands subscale of the Work Limitations Questionnaire. 21 Questions were as follows: In the past 2 weeks, how much of the time did your urinary symptoms make it difficult for you to do the following at your job: work the required number of hours; get along easily at the beginning of the workday; start on your job as soon as you arrived at work; do your work without taking numerous bathroom breaks; stick to a routine or schedule? The response options were: difficult none of the time (0%); difficult a slight bit of the time; difficult some of the time (50%); difficult most of the time; difficult all of the time (100%). Urinary-specific work impairment scores were computed by adding the responses and dividing by the number of items; scores were then multiplied by 25, generating a scale score of 0 (least limited) to 100 (most limited). Thus, a urinary-specific VOL. 15, No. 4 n The American Journal of Managed Care n S99

Reports work impairment score of 30, for example, indicates that the respondent was limited in performing these demands during 30% of the reporting period. Participants were also asked to rate their agreement with 3 statements used in prior populationbased survey research to estimate OAB prevalence: (1) You always worry about interrupting meetings with frequent trips to the bathroom ; (2) You have changed jobs, retired early, or been fired because of your urinary symptoms ; (3) Your urinary symptoms have been a factor in decision related to where you work or the hours you work. Response options for each of these questions were: agree completely; agree somewhat; disagree somewhat; disagree completely. Statistical Analyses All statistical analyses were performed using SAS Version 9.1.3. Sample matching was used to construct a population-representative sample of respondents within each country s Internet-based panel, and poststratification weights were calculated to correct small amounts of imbalance based on differences in response rates. 20 Demographic variables and work productivity outcomes were evaluated by descriptive analyses and are presented by OAB subgroup separately for men and women. General linear models with Scheffe s post hoc subgroup comparisons were used to compare OAB subgroups. Linear and logistic regressions were performed to evaluate the predictors of n Table 1A. Demographics of Working US Participants Aged 40 to 65 by Overactive Bladder (OAB) Status: Men Characteristics, n (%) No/Minimal Symptoms N = 1893 Continent OAB N = 538 Incontinent OAB N = 445 P Age, y, mean (SD) 49.3 (6.2) 51.1 (6.9) 51.8 (6.4) 1*, 2* a Race, n (%) b White 1401 (74.0) 348 (64.7) 303 (68.1) <.0001 Black 165 (8.7) 83 (15.4) 72 (16.2) Asian 81 (4.3) 15 (2.8) 22 (4.9) Hispanic 215 (11.4) 80 (14.9) 46 (10.3) Other 32 (1.7) 12 (2.2) 2 (0.4) Marital status, n (%) b Single 268 (14.2) 76 (14.1) 56 (12.6).1874 Married/living with partner 1366 (72.2) 364 (67.7) 313 (70.3) Divorced 241 (12.7) 89 (16.5) 71 (16.0) Widow/widower 17 (0.9) 10 (1.9) 5 (1.1) Missing 1 (0.0) 0 (0.0) 0 (0.0) Education, n (%) b High school or less 597 (31.5) 184 (34.2) 160 (36.0).7547 Some college 590 (31.2) 169 (31.4) 132 (29.7) 4-year college 403 (21.3) 101 (18.8) 87 (19.6) Postgraduate 302 (16.0) 84 (15.6) 66 (14.8) Missing 1 (0.0) 0 (0.0) 0 (0.0) Current employment status, n (%) b Working full-time 1735 (91.7) 463 (86.1) 391 (87.9).0005 Working part-time 130 (6.9) 66 (12.3) 44 (9.9) Other work for pay 29 (1.5) 9 (1.7) 11 (2.5) a Significant differences between age means using Scheffe s test adjusting for multiple post hoc pairwise comparisons: 1 = No symptoms vs incontinent OAB, 2 = No symptoms vs continent OAB, and 3 = Continent OAB vs incontinent OAB. b All N s presented are weighted; subgroups may or may not equal total N due to rounding or weighted values. *P <.001. S100 n www.ajmc.com n MARCH 2009

Impact of Overactive Bladder on Work Productivity in the United States: Results From EpiLUTS urinary-specific work productivity scores and binary outcomes of work interference (agreement/disagreement). Regression models included age, race, education level, number of comorbid conditions, and body mass index as covariates, followed by the frequency of individual LUTS. Given the large sample size and multiple analyses conducted, a P value of <.01 was used as the threshold for statistical significance. RESULTS The US response rate was 60%. Of the 20,000 participants (9416 men, 10,584 women) in the total US sample, 5301 men and 4394 women were age 40 to 65 and were working full- or part-time. Using the cutpoint of sometimes or more often, 10.2% (n = 538) of men had continent OAB, 8.4% (n = 445) had incontinent OAB, 35.7% (n = 1893) had no/minimal LUTS, and 45.7% (n = 2425) had other non-oab LUTS symptoms at least sometimes or more often and, thus, were not included in subsequent subgroup analyses. Among women, 12.0% (n = 521) had continent OAB, 25.6% (n = 1126) had incontinent OAB, 26.7% (n = 1173) had no/minimal LUTS, and 35.8% (n = 1574) had other non-oab LUTS symptoms at least sometimes and were excluded from subgroup analyses. Analyses conducted using a response of often or more often showed a similar pattern of results, with greater impairments noted. To simplify, results n Table 1B. Demographics of Working US Participants Aged 40 to 65 by Overactive Bladder (OAB) Status: Women Characteristics, n (%) No/Minimal Symptoms N = 1173 Continent OAB N = 521 Incontinent OAB N = 1126 P Age, y, mean (SD) 49.5 (6.4) 49.8 (6.5) 51.1 (6.5) 1*, 3* a Race, n (%) b White 827 (70.5) 333 (63.9) 826 (73.4) <.0001 Black 132 (11.3) 74 (14.2) 144 (12.8) Asian 61 (5.2) 16 (3.1) 23 (2.0) Hispanic 136 (11.6) 95 (18.2) 116 (10.3) Other 16 (1.4) 4 (0.8) 17 (1.5) Marital status, n (%) b Single 133 (11.3) 57 (10.9) 103 (9.1).1186 Married/living with partner 752 (64.1) 316 (60.7) 725 (64.4) Divorced 242 (20.6) 132 (25.3) 238 (21.1) Widow/widower 44 (3.8) 15 (2.9) 57 (5.1) Missing 1 (0.1) 1 (0.2) 3 (0.3) Education, n (%) b High school or less 574 (48.9) 289 (55.5) 569 (50.5).0018 Some college 261 (22.3) 130 (25.0) 293 (26.0) 4-year college 188 (16.0) 60 (11.5) 143 (12.7) Postgraduate 151 (12.9) 43 (8.3) 121 (10.7) Current employment status, n (%) b Working full-time 846 (72.1) 388 (74.5) 755 (67.1).0186 Working part-time 294 (25.1) 118 (22.6) 334 (29.7) Other work for pay 34 (2.9) 15 (2.9) 37 (3.3) a Significant differences between age means using Scheffe s test adjusting for multiple post hoc pairwise comparisons: 1 = No symptoms vs incontinent OAB, 2 = No symptoms vs continent OAB, and 3 = Continent OAB vs incontinent OAB. b All N s presented are weighted; subgroups may or may not equal total N due to rounding or weighted values. *P <.001. VOL. 15, No. 4 n The American Journal of Managed Care n S101

Reports n Table 2A. Work Productivity by Overactive Bladder (OAB) Subgroups > Sometimes: US Men Aged 40 to 65 Currently Working No/Minimal Symptoms N = 1893 Continent OAB N = 538 Incontinent OAB N = 445 P Work Limitations Questionnaire total score, mean (SD) N = 1483 0.6 (4.2) N = 533 9.3 (14.3) Always worry about interrupting meetings N = 1481 N = 533 with frequent trips to bathroom, n (%) b 12.5 (16.7) 1*, 2*, 3* a Agree completely 42 (2.8) 33 (6.2) 26 (5.8) <.0001 Agree somewhat 13 (0.9) 110 (20.6) 126 (28.3) Disagree somewhat 42 (2.8) 92 (17.3) 73 (16.4) Disagree completely 1384 (93.5) 299 (56.1) 219 (49.2) Have changed jobs, retired early, or been fired because of your urinary symptoms, n (%) b N = 1475 N = 527 Agree completely 43 (2.9) 5 (0.9) 6 (1.3) <.0001 Agree somewhat 2 (0.1) 4 (0.8) 8 (1.8) Disagree somewhat 6 (0.4) 13 (2.5) 17 (3.8) Disagree completely 1424 (96.5) 505 (95.8) 411 (92.4) Your urinary symptoms have been a factor in decisions related to where you work or the hours you work, n (%) b N = 1483 N = 530 Agree completely 42 (2.8) 10 (1.9) 17 (3.8) <.0001 Agree somewhat 5 (0.3) 33 (6.2) 32 (7.2) Disagree somewhat 8 (0.5) 32 (6.0) 28 (6.3) Disagree completely 1428 (96.3) 454 (85.7) 365 (82.0) a Significant differences between Work Limitations Questionnaire score means using Scheffe s test adjusting for multiple post hoc pairwise comparisons: 1 = No symptoms vs incontinent OAB, 2 = No symptoms vs continent OAB, and 3 = Continent OAB vs incontinent OAB. b All N s presented are weighted; subgroups may or may not equal total N due to rounding or weighted values. *P <.001. using the cutpoint of sometimes or more often are presented here. Participant demographic information is presented separately for men (Table 1A) and women (Table 1B) by OAB subgroup. Among men, those with no/minimal symptoms were slightly younger (mean age, 49.3 years; standard deviation [SD], 6.2) than those with continent OAB (mean age, 51.1 years; SD, 6.9) and incontinent OAB (mean age, 51.8 years; SD, 6.4). A similar pattern was evident among women, with those with no/minimal symptoms being the youngest (mean age, 49.5 years; SD, 6.4), followed by those with continent OAB (mean age, 49.8 years; SD, 6.5), and incontinent OAB (mean age, 51.1 years; SD, 6.5). The sample was diverse with respect to race and reflective of the US population. Men with no/minimal symptoms were more likely to be working fulltime (92% vs 86% and 88% in the continent OAB and incontinent OAB groups, respectively). The proportion of women working full-time was lower across groups (no/minimal symptoms, 72%; continent OAB, 75%; incontinent OAB, 67%), with a higher percentage of women working part-time. Mean urinary-specific work impairment scores were highest for individuals with incontinent OAB (men, 12.5%; women, 12.6%), followed by continent OAB (men, 9.3%; women, 10.8%), and no/minimal symptoms (men, 0.6%; women, 1.0%), indicating that men and women with incontinent OAB were limited in performing their job demands 13% of the time in the prior 2 weeks (Tables 2A and 2B). In parallel, over a third of men (34%) and women (36%) in this group reported always worrying about interrupting meetings with frequent S102 n www.ajmc.com n MARCH 2009

Impact of Overactive Bladder on Work Productivity in the United States: Results From EpiLUTS n Table 2B. Work Productivity by Overactive Bladder (OAB) Subgroups > Sometimes: US Women Aged 40 to 65 Currently Working No/Minimal Symptoms N = 1173 Continent OAB N = 521 Incontinent OAB N = 1126 P Work Limitations Questionnaire total score, mean (SD) N = 958 1.0 (5.3) N = 516 10.8 (15.6) N = 1106 12.6 (16.7) Always worry about interrupting meetings N = 957 N = 513 N = 1104 with frequent trips to bathroom, n (%) b Agree completely 35 (3.7) 31 (6.0) 115 (10.4) <.0001 Agree somewhat 16 (1.7) 129 (25.1) 287 (26.0) Disagree somewhat 57 (6.0) 86 (16.8) 220 (19.9) Disagree completely 850 (88.8) 267 (52.0) 483 (43.8) Have changed jobs, retired early, or been fired N = 956 N = 513 N = 1106 because of your urinary symptoms, n (%) b Agree completely 37 (3.9) 10 (1.9) 20 (1.8) <.0001 Agree somewhat 1 (0.1) 9 (1.8) 16 (1.4) Disagree somewhat 6 (0.6) 12 (2.3) 41 (3.7) Disagree completely 912 (95.4) 482 (94.0) 1029 (93.0) Your urinary symptoms have been a factor in decisions related to where you work or the hours you work, n (%) b N = 957 N = 515 N = 1103 Agree completely 34 (3.6) 23 (4.5) 62 (5.6) <.0001 Agree somewhat 1 (0.1) 34 (6.6) 105 (9.5) Disagree somewhat 11 (1.1) 42 (8.2) 79 (7.2) Disagree completely 910 (95.1) 417 (81.0) 857 (77.7) a Significant differences using Scheffe s test adjusting for multiple post hoc pairwise comparisons: 1 = No symptoms vs incontinent OAB, 2 = No symptoms vs continent OAB, and 3 = Continent OAB vs incontinent OAB. b All N s presented are weighted; subgroups may or may not equal total N due to rounding or weighted values. *P <.001. 1*,2*, 3* a trips to the bathroom, compared with 27% and 31% of men and women with continent OAB and 4% and 5% of men and women with no/minimal symptoms. Across groups, less than 4% of men and women reported that their urinary symptoms were a factor in job changes, such as early retirement or being fired. Interestingly, the proportion who endorsed this statement was highest among women in the no/minimal symptoms group (3.9%) and was similarly elevated among men with no/minimal symptoms (3.0%). However, it is important to note that in this age cohort of <65 years, the percentage of men who are retired is significantly higher among men with continent OAB (15%) and incontinent OAB (18%) compared with men with no/minimal symptoms (10%). Although retirement rates among women are similar across groups, rates of permanent disability are significantly higher among continent and incontinent men and women with OAB (continent: men 16%, women 10%; incontinent: men 18%, women 14%) as compared with those with no/minimal symptoms, in which the permanently disabled rate is 4% for both men and women. The proportion of men and women who reported that their urinary symptoms had been a factor in decisions related to where they worked or their work hours was highest among those with incontinent OAB (men, 11%; women, 15%), followed by those with continent OAB (men, 8%; women, 11%) and no/minimal symptoms (men, 3%; women, 4%). As noted above, effects were more pronounced for those with continent OAB when the cutpoint often or more often was used to define groups. For example, 17% of men and 21% of women with continent OAB defined as often or more often reported that their urinary VOL. 15, No. 4 n The American Journal of Managed Care n S103

Reports n Table 3. Summary of Linear and Logistic Regressions Urinary-Specific Work Impairment Scores (higher scores indicate greater impairment) Parameter Estimate Worry About Interrupting Meetings (agree/disagree) Parameter Estimate Men Women Men Women Covariates Age -0.064 a -0.091 b -0.021-0.022 b Race Hispanic vs white -0.873-0.091-0.207-0.085 Other vs white -0.301-0.559 0.656-0.010 Asian vs white -0.168 2.870 b 0.049-0.278 Black vs white -1.031 0.978-0.250-0.263 Body mass index -0.035-0.048 0.017 0.003 Number of comorbid conditions 0.600 c 0.660 c 0.049 0.066 Education Postgraduate vs high school -0.483-2.011 b 0.181 0.165 Four-year college vs high school -0.245-1.098 0.186 0.064 Some college vs high school -0.234-1.279 b -0.175-0.020 Lower urinary tract symptoms Perceived frequency 4.438 c 5.508 c 1.245 c 1.235 c Nocturia d 0.271 c 0.167 0.104 c 0.032 Urgency 0.817 c 0.968 a 0.136 0.138 Urgency with fear of leaking 2.232 c 0.960 b 0.377 c 0.316 c UUI 0.832 a 0.941 c 0.023 0.038 SUI (laughing, sneezing, coughing) 1.340-0.235-0.017 0.031 SUI (physical activities) 1.189 1.312 b -0.031 0.099 Leak for no reason 1.334 0.580 0.301 0.079 Nocturnal enuresis 1.318 b 1.025 b 0.340 0.011 Leak during sexual activity 0.517 0.210-0.126 0.226 Weak stream -0.291-0.034-0.162 0.086 Split stream 0.300 1.140 c 0.096 0.081 Intermittency -0.099 0.605-0.060 0.042 Hesitancy 0.512 b 1.030 a 0.170 0.088 Straining 1.445 c 1.533 c 0.194 0.058 Terminal dribble 0.001-0.006 0.001 0.041 Incomplete emptying 0.932 c 0.882 a 0.322 c 0.094 Postmicturition incontinence -0.058 0.289 0.230-0.001 Bladder area pain 2.221 c 1.316 0.157 0.229 Dysuria 1.512 2.574 b 0.374-0.136 SUI indicates stress urinary incontinence; UUI, urgency urinary incontinence. a P <.001. b P <.01. c P <.0001. d Entered into the model as a continuous variable, as it was collected. S104 n www.ajmc.com n MARCH 2009

Impact of Overactive Bladder on Work Productivity in the United States: Results From EpiLUTS symptoms had been a factor in decisions related to where they worked or work hours. Results from the linear and logistic regressions to evaluate the predictors of urinary-specific work impairment scores and binary outcomes of worry about meeting interrupting due to frequent bathroom visits (agree/disagree) are presented in Table 3. Additional logistic regressions were performed for binary outcomes based on participant agreement with the 2 other work-interference statements ( changed jobs, retired early, or been fired because of your urinary symptoms ; and urinary symptoms have been a factor in decision related to where you work or the hours you work ); however, these models yielded poor fit and, thus, are not presented here. Age was significantly associated with urinary-specific work impairment in both men and women and with worry about interrupting meetings in women, with younger age related to lower productivity and increased likelihood of worry. Increasing numbers of comorbid conditions were related to lower scores (indicating more impairment) for both men and women, whereas lower levels of education (high school as compared with some college and postgraduate) were related to more impairment in women. Asian women reported higher urinary-specific work impairment as compared with white women. Among LUTS, significant associations with work impairment and increased worry were present for a number of storage symptoms. Urgency associated with a fear of leaking urine and perceived daytime frequency were the most consistently robust LUTS associated with productivity outcomes for both men and women. In men, nocturia was related to higher work impairment and worry about interrupting meetings. Other storage symptoms significantly linked to work impairment scores for both men and women included urinary urgency (without qualification of fear of leaking), urgency incontinence, and nocturnal enuresis. Significant associations for voiding symptoms in relation to urinary-specific work impairment included split stream in women and hesitancy and straining in both men and women. Links for postmicturition symptoms included incomplete emptying for both men and women in relation to work impairment and, for men, in relation to worry about interrupting meetings. Other significant predictors of work impairment were bladder area pain for men and dysuria for women. DISCUSSION This is the first paper to describe in detail the impact of OAB on work productivity in the United States. As in EPIC, OAB was associated with similar levels of diminished work productivity in men and women with the most pronounced impact among those with UUI. Irwin et al 17 found that men and women with OAB both with and without UUI were more likely to report absenteeism and presenteeism compared with controls. In terms of the impact of symptoms on daily work activities, findings indicated that a substantial proportion of men and women with OAB particularly those with incontinence worry about interrupting meetings and have considered their urinary symptoms in decisions about work location and hours. However, our findings differ somewhat from another cross-sectional population-based survey in 6 European countries, 15 which demonstrated that men with OAB and incontinence were significantly more likely to report impact on their daily work life as compared with women. Results for men and women with OAB and incontinence in the present study were generally similar, with women reporting slightly higher rates than men. For example, 38% of men versus 22% of women with incontinent OAB in Irwin et al 15 reported worrying about interrupting meetings due to bathroom frequency as compared with 34% of men and 36% of women in EpiLUTS; and 21% of men and 8% of women with incontinent OAB in Irwin et al 15 reported that their symptoms affected decisions about work location and hours as compared with 11% of men and 15% of women in EpiLUTS. One surprising result in the present study was that men and women with no/minimal symptoms were as or more likely to report they had changed jobs, retired early, or been fired as a result of their urinary symptoms as those with OAB. The most likely explanation for this finding that may also account for some of the aforementioned differences between the present study and prior research is that only those who were currently working were included in the present study. As noted previously, men with OAB in EpiLUTS were significantly more likely to be retired (continent OAB: men, 15%; incontinent OAB: men, 18%), and men and women with OAB were significantly more likely VOL. 15, No. 4 n The American Journal of Managed Care n S105

Reports to be permanently disabled (continent OAB: men, 16%, women, 10%; incontinent OAB: men, 18%, women, 14%) than those with no/minimal symptoms (retired: men, 10%; permanently disabled: men and women, 4%). Thus, a substantial proportion of men and women whose work productivity may have been compromised by OAB possibly even to the point of contributing to an early retirement or disability were not included in this analysis. This limitation notwithstanding, it should be noted that the no/minimal symptoms group does include participants who have reported experiencing 1 or more LUTS rarely or more often. While the proportion of those bothered using this cutpoint was dramatically less than that using the more conservative cutpoint of sometimes or more often (data not shown here), there was a small contingency of participants who reported negative consequences in their life as a result of these symptoms. Other factors that may explain differences between results observed here and those reported in Irwin et al 15 include discrepancies in how OAB was defined and cultural differences (data presented here include men and women from the United States, whereas the sample in Irwin et al 15 comprised individuals from France, Germany, Italy, Spain, Sweden, and the United Kingdom). In addition to examining differences in work outcomes by OAB subgroups, the present study evaluated the relative contribution of other LUTS. Results of linear and logistic regressions indicated that urgency accompanied by a fear of leaking and perceived daytime frequency were most strongly associated with work productivity impairment in both men and women, while links were also evident for other typical OAB storage symptoms (nocturia, urgency, and UUI) as well as voiding and postmicturition symptoms, dysuria, and bladder area pain. In terms of clinical implications, these findings underscore the importance of assessing the symptom frequency and impact of all LUTS in evaluating treatment options. Several limitations to this study bear mentioning. First, the data are cross-sectional, preventing any inference about a potential causal relationship between the experience of symptom frequency and symptom-specific bother and treatment seeking. Other factors that were not measured in this study such as other health and psychological conditions may also account for differences in work productivity. The potential for study bias resulting from an Internet-based sample poses some risk to generalizability related to Internet usage; however, it is important to note that the most recent population census was used as the basis for creating a target sample to ensure that the data collected would be representative of the general population according to the demographics of age, sex, race, and education. 19 Taken together, findings presented here demonstrate that OAB and other LUTS are associated with decreases in individuals daily work functioning and add to existing evidence documenting the larger economic costs of OAB. As only working Americans were included in this study, findings presented here represent a conservative estimate of the impact of OAB and other LUTS. The higher rates of early retirement among individuals with OAB present a real burden to society as there is a total loss of productivity while many individuals will draw on employer retirement benefits. Using data from a 2000 national postal survey in the United States, the total economic cost of urinary incontinence and OAB was estimated to be $19.5 billion and $12.6 billion. 18 These estimates suggest that the societal burden of OAB is comparable to that of osteoporosis and gynecologic and breast cancer. 18 conclusion In this large US population-based study, OAB was highly prevalent among both men and women and was associated with lower levels of work productivity and interference with work-related activities with particularly pronounced effects observed among those with incontinent OAB. In addition to the associations observed for OAB, findings from regression analyses indicated that a number of other storage, voiding, and postmicturition LUTS are associated with diminished work productivity. These findings add to the literature documenting the burden of OAB and underscore the need for increased screening and treatment. Furthermore, these findings highlight the loss in productivity associated with OAB and point to the need for future cost-benefit analyses to examine treatment benefits from an economic perspective. S106 n www.ajmc.com n MARCH 2009

Impact of Overactive Bladder on Work Productivity in the United States: Results From EpiLUTS Acknowledgments Editorial assistance was provided by United BioSource Corporation Center for Health Outcomes Research and funded by Pfizer Inc. Coordination support and management of this supplement were provided by Complete Healthcare Communications, Inc. Author Affiliations: From Center for Health Outcomes Research, United BioSource Corporation, Bethesda, MD (CCS, KSC); Pfizer Inc, New York, NY (VV, ZSK); Department of Epidemiology, University of North Carolina, Chapel Hill, NC (DEI); Department of Veterans Affairs, Health Economics Resource Center, Menlo Park, CA (THW). Funding Source: Financial support for this work was provided by Pfizer Inc. Author Disclosures: The authors report the following: consultant to Pfizer Inc (CCS, KSC, DEI); employee at Pfizer Inc (VV, ZSK). THW reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Authorship Information: Concept and design (CCS, KSC, VV, ZSK, DEI); acquisition of data (CCS, KSC, VV, ZSK); analysis and interpretation of data (CCS, KSC, VV, ZSK, DEI, THW); drafting of the manuscript (CCS, KSC, VV, ZSK, THW); critical revision of the manuscript for important intellectual content (CCS, VV, ZSK, DEI, THW); statistical analysis (CCS, KSC, VV, ZSK, THW); provision of study materials or patients (CCS, VV, ZSK); obtaining funding (KSC, VV, ZSK); administrative, technical, or logistic support (CCS, VV, ZSK); and supervision (CCS, KSC, VV, ZSK). Address correspondence to: Chris C. Sexton, PhD, Senior Research Associate, Center for Health Outcomes Research, United BioSource Corporation, 7101 Wisconsin Ave, Ste 600, Bethesda, MD 20814. E-mail: chris.sexton@unitedbiosource. com. References 1. 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